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The Pros and Cons of Using Larger Femoral Heads in Total Hip Arthroplasty

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The Pros and Cons of Using Larger Femoral Heads in Total Hip Arthroplasty A Review Paper The Pros and Cons of Using Larger Femoral Heads in Total Hip Arthroplasty Pranav Rathi, MBBS, MS, Gavin C. Pereira, MBBS, FRCS (Eng), FRCS (T&O), Mauro Giordani, MD, and Paul E. Di Cesare, MD Twenty-five percent of all revisions are performed for instabil- Abstract ity or dislocation.3 With the introduction of improved bearing sur- faces for total hip arthroplasty (THA) has come Total Hip Arthroplasty Stability a reintroduction of larger femoral heads with the and Jump Distance promise of reducing the rate of hip instability Jump distance (JD) is the femoral head center translation dis- and increasing hip range of motion (ROM). The tance required for a head to dislocate from a socket (Figure 1). size of femoral heads used for THA ranges from Prosthetic hips with less JD are more likely to dislocate than 22 to 40 mm, and even larger heads are used hips with more JD. Sariali and colleagues5 found that JD varies for hip resurfacing. With accurately positioned according to cup abduction angle (angle of rotation around components, larger heads reduce the hip insta- anterior-posterior axis of pelvis), cup anteversion angle (angle bility rate and theoretically increase hip ROM. of rotation around cranial-caudal axis of pelvis), femoral head However, for any given bearing surface, the vol- diameter, and cup center offset. umetric wear rate is higher for larger heads than Cup center offset is the shortest distance from the center of for smaller heads, which potentially jeopardizes the head to the opening plane of the cup (Figures 2A-C). The the long-term survival of these reconstructions.AJO offset is positive when the head center lies outside the opening In this article, we review the evidence for use of larger femoral heads with respect to stability, ROM, impingement, wear rate, bearing surfac- Figure 1. Jump distance (JD): distance of translation of femoral es, and future directions. head center required for head to dislocate from cup. Prosthetic hips with less JD are likelier to dislocate more easily than those DO NOTwith more JD.COPY ecent advances in total hip arthroplasty (THA) bearing materials, such as cross-linked polyethylene, ceramics, R and metal, have reduced the rate of bearing wear. The prospect of decreased wear (attributed to improved bearing materials) and the perception of a lowered rate of hip dislo- cation have prompted surgeons to use larger femoral heads for THA. The validity of this approach has not been proved. Femoral heads ranging from 22 to 40 mm are available for THA, and even larger heads are used for hip resurfacing. Both the type of material and size selected for femoral heads may af- fect dislocation rate, linear wear, and range of motion (ROM). In this article, we review the evidence for use of larger femoral heads with respect to stability, ROM, impingement, wear rate, bearing surfaces, and future directions. Dislocation rates are 0.5% to 10% for primary THA1 and 10% to 25% for revision THA.2 Up to one-third of hip disloca- tions become recurrent and require revision surgery.3 Every closed reduction episode increases hospital costs—by 19% for an uncomplicated THA—and by 148% for a revision THA.4 Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com August 2013 The American Journal of Orthopedics® E53 The Pros and Cons of Using Larger Femoral Heads in THA P. Rathi et al A B C Figure 2. Cup center offset: neutral (A), positive (B), and negative or inset (C). AJO DO NOT COPY Figure 3. Jump distance (JD) decreases as cup abduction angle increases from 25° to 70°. plane of the cup, which is the case when the cup is not a full It is only partly true that JD increases with femoral head hemisphere or when the acetabular liner is offset to increase diameter. The equation highlights that JD depends not only the amount of material medially in the polyethylene liner. The on femoral head size, but also on orientation of the implanted offset is negative (and is called an inset) when the head center lies cup and on cup offset. The position of the implanted cup in inside the opening plane of the cup. turn has 2 variables that affect JD: abduction angle and ante- The surgeon controls the variables of cup abduction angle, version angle. cup anteversion angle, and femoral head diameter, and JD is For a constant anteversion angle and a constant femoral head calculated as follows: size, JD is inversely related to the abduction angle (Figure 3). For example, for a 32-mm head, JD decreases about 0.25 mm π offset − arcsin JD = 2R × 2 θ ()R for each 1° increase in abduction angle. []2 With respect to constant anteversion angle and constant where R = femoral head radius, θ = planar cup inclination abduction angle, JD is directly related to femoral head size. angle, and offset = cup center offset. The planar cup inclina- However, this advantage of increased JD is reduced if the cup tion angle is given by: is implanted with an increased abduction angle, ie, vertical cup placement. ϴ = arctan [ tan α × cos β ] For an acetabular component at an abduction angle of 30°, JD increases 0.5 mm for each 1-mm increase in head diameter; where α = abduction angle of cup, and β = anteversion angle at an abduction angle of 45°, JD increases 0.4 mm; and, at an of cup. abduction angle of 60°, JD increases 0.25 mm. The JD increase E54 The American Journal of Orthopedics® August 2013 www.amjorthopedics.com The Pros and Cons of Using Larger Femoral Heads in THA P. Rathi et al Figure 4. Jump distance decreases as cup center offset increases. that occurs with larger head diameter depends on the abduc- femoral head offset at the start. For a 1-mm increase in head tion angle/inclination of the cup, and much of that advantage offset, JD is decreased by 0.92 mm. Generally, in large-diam- can be lost when the cup is inserted at a higher than desired eter head–cup couples (head size, >38 mm), the head offset abduction angle. For example, in a cup inserted at 45°, JD is increased by about 3 mm. In these cases, JD is 2.76 mm increases from 14.1 mm for a 36-mm head to 15.8 mm for a less than the JD for a corresponding hemispherical cup design. 48-mm head—a difference of 1.7 mm (12%), which drops to When comparing JD for a 32- to 40-mm head diameter, one 0.13 mm (1.4%) for a cup abduction angle of 60°.AJOmust consider the acetabular couple and the respective femoral JD also varies directly with the anteversion of the acetabu- head offset because each may have a similar JD. This is why lar component, but this variation has less effect per degree use of very large heads results in a smaller increase in JD than of position change than the abduction angle.5 This is because expected, and may be why similar dislocation rates are found the anteversion angle is a low-value angle (15°-25°) from the in comparisons of 32-mm heads and larger heads.5 start, and consequently, the trigonometric value of this angle The biomechanical basis for the increased stability of larger is almost negligible. femoral heads in THA has received support from clinical data. DOThe other variable that affects NOTJD is cup center offset. This According COPYto an analysis of 42,987 primary THAs from 1987 relationship is inverse, ie, as offset increases, JD decreases. to 2000 (The Norwegian Arthroplasty Registry), the rate of Increasing the offset causes the center of rotation to lay outside revision surgery for instability was lower for patients with the opening plane of the cup, thereby making the cup shal- larger femoral heads (30-32 mm) than for patients with smaller lower and increasing susceptibility to dislocation (Figure 4). femoral heads (≤28 mm).7 In a separate analysis of a polished, Decreasing the offset, or having an inset (as in a constrained tapered, cemented stem (Exeter; Howmedica Osteonics, Caen, liner), can increase the risk for impingement. However, Bunn France) and an all-polyethylene, cemented cup (Exeter; How- and colleagues6 studied ROM in a computer-generated pelvis medica Osteonics, Caen, France) used in THAs with 26-, 28-, with a Secur-Fit Max Femoral Hip Stem (Stryker Orthopaedics, and 30-mm heads (same registry), the reoperation rate was Mahwah, New Jersey) and a Trident Acetabular Cup System higher for patients with 26-mm heads (because of dislocation) (hemispherical with 0 cup center offset; Stryker Orthopae- than for patients with 30-mm heads.7 The higher reoperation dics, Mahwah, New Jersey) and concluded that bony impinge- risk after dislocation persisted even after adjusting for several ment—not implant impingement—reduced ROM. potential confounders. It should be noted that this registry did As femoral head size increases, the polyethylene liner thins not capture hip dislocations for which there was no reopera- to accommodate it, but only to a point (the liner has a certain tive repair. minimum thickness). Therefore, femoral heads larger than In 2005, the Mayo Clinic reported on 21,047 THAs per- 38 mm require larger acetabular components so that a liner of formed between 1969 and 1999 to determine the effect of at least minimum permissible thickness can be used. In theory, femoral head diameter on risk for dislocation.8 Many factors the surgeon can decide to ream for a larger cup to accommo- were stratified and adjusted to isolate head diameter as a single date the larger head, creating more acetabular bone loss.
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